Death is an inevitable part of life and nurses are frequently called upon to perform end-of-life (EOL) care. The American Association of Colleges of Nursing (AACN, 2016), National League of Nursing (NLN, n.d.), American Nurses Association (ANA, 2016), and the Institute of Medicine (IOM, 2008) agree that nursing education should prepare nursing students to manage and perform EOL care. Therefore, EOL education is imperative for undergraduate nursing students. The End-of-Life Nursing Education Consortium (ELNEC) was formed in 2000 to address deficits in nursing education concerning EOL. ELNEC has identified 15 competencies that are essential for undergraduate nursing students to achieve in order to provide quality care to the dying client (AACN, 2017). In 2017, the ANA and Hospice and Palliative Nurses Association published a Call for Action: Nurses Lead and Transform Palliative Care which recommended that ELNEC curricula be adopted as the standard for primary palliative care education for pre-licensure nurses. Primary palliative care includes care for the dying and support for grieving loved ones. Nurse educators need to identify effective strategies to integrate this content into existing undergraduate nursing courses. The use of simulation with standardized patients (SPs) and a high-fidelity mannequin is an effective strategy that could be integrated throughout the curricula to evaluate a student’s EOL skills (Jeffries, 2012).
The purpose of this study was to examine differences in attitudes of sophomore level undergraduate nursing students in caring for a dying patient before and after a multimodal educational experience consisting of lecture and an unfolding case study presented as part of a simulation experience.
Methods
A quasi-experimental, pretest/posttest design with a convenience sample was used for this study. The study was conducted as part of a Foundations of Professional Nursing course taught in the second semester of sophomore year at a private university in the eastern region of the United States. Students were required to participate in a lecture and simulation as part of the course and clinical requirements. Participation in the study was voluntary. Of the 58 students enrolled in this cohort, 54 students agreed to participate in the study. The study was reviewed by the university’s institutional review board.
Frommelt’s Attitudes Towards Care of the Dying (FATCOD) version A was used to measure attitudes towards care of the dying patient pre and post educational intervention. A Cronbach α co-efficient of .79 on the pretest and .84 on posttest suggests good internal consistency for this instrument.
In addition to quantitative measurement of attitudes, qualitative measurement was obtained through analysis of three open-ended questions completed by participants. The three questions included: How did the educational experience prepare you for caring for a dying client?; What part of the experience had the greatest impact on you?; and What else do you feel you need to help you become more confident in caring for a dying client and their family? Content analysis was conducted by two members of the research team. Data were read several times by each researcher to ascertain patterns of ideas. The two researchers worked independently to develop codes and to the development of themes. Researchers participated in consensus procedures throughout this process to clarify discrepancies and facilitate accurate interpretation of data.
Procedure
Students participated in an interactive lecture which incorporated content from the ELNEC modules that addressed hospice and palliative care, caring for the dying patient, grief loss, and bereavement, and communication. Faculty presenters had expertise in palliative and hospice care and had received training to facilitate ELNEC courses. Prior to this lecture, students received information about the study and had an opportunity to review the informed consent form. Students were informed that while the participation in the lecture and simulation was a course requirement, participation in the study was voluntary.
Over the remaining weeks of the course, students participated in a simulation experience focused on end of life care. The simulation was adapted from the National League of Nursing’s (NLN) Advanced Care Excellence for Seniors (ACE-S) simulation scenario on end of life care. The simulation was conducted in the university’s Interprofessional Simulation Center. The simulation focused on providing care and support to a dying female client and her partner. A high-fidelity simulator was used for the client and an SP played the role of the client’s partner. After the simulation, the participants were debriefed by the simulation coordinator and the SPs. Debriefing allows the participants the opportunity to reflect on their actions, feelings, and reactions to the experience (Dreifuerst, 2012). The students completed the demographic questionnaire, post-test instrument, and open-ended questionnaire after the debriefing.
Results
Descriptive statistics showed participants (N = 54) were between the ages of 18-27 years. Of the 54 subjects, the majority was female (42%), Catholic (64.7%), and most were Caucasian (74.5%).
The FATCOD pretest mean was 118.23 (SD ± 9.9; range 30 – 150) and the posttest mean was 123.92 (SD ± 10.7; range 30-150). A paired t-test revealed a statistically significant difference between the pretest and posttest (p = .003), suggesting that students gained a more positive attitude towards caring for the dying client.
Content analysis of the open-ended questions revealed three themes for the first question including: knowing what to say and how to offer presence, becoming emotionally prepared, and learning skills to comfort. The second question identified four elements of the study students felt had the greatest impact including: the crying family member (patient and/or family’s emotions), communicating death (to spouse or patient), debriefing, and consoling family. The third question revealed three things the students felt they would need to increase their confidence in caring for a dying patient including: more experience, practice caring in death and dying situations, and more EOL simulation.
Discussion
It is imperative that EOL care be integrated into undergraduate nursing education. Leading bodies of nursing have called for an increase in educating nursing students on EOL care. This study examined a multimodal approach to EOL care including a specifically designed lecture and simulation. Results of the study revealed a statistically significant increase in students’ attitudes towards caring for the dying client following lecture and simulation. In addition, qualitative results showed the positive impact students revealed following these educational strategies.